Faculty Bibliography

Individuals with severe mental illness (SMI) face significantly reduced life expectancy, mainly driven by natural causes such as cardiovascular disease, pulmonary disease, cancer, and stroke. Although medical care has advanced, the mortality gap between individuals with SMI and the general population has continued to expand in many countries over recent decades. This disparity is exacerbated by systemic healthcare inequities, fragmented healthcare, insufficient use of preventive measures, and the burden of multimorbidity. This paper proposes six actionable strategies to reduce the excess mortality associated with SMI by integrating physical healthcare into psychiatric services. Across all recommendations, we explicitly embed lifestyle interventions, especially structured physical activity given its comparatively stronger evidence base in SMI, alongside sleep and nutrition support delivered through pragmatic, accessible programs. First, psychoeducation should be expanded to include physical health literacy. Second, structured smoking cessation programs must be implemented. Third, early identification and management of obesity, including pharmacological interventions, should be prioritized. Fourth, hypertension should be routinely screened and treated within psychiatric settings. Fifth, dyslipidaemia and diabetes require systematic monitoring and timely initiation of statins, metformin and GLP-1 receptor agonists. Sixth, these interventions must be delivered through integrated care models that ensure continuity, optimal self-management, and long-term outcome monitoring. Together, these six approaches offer a framework to narrow the mortality gap between people with SMI and the general population, as well as support a shift toward holistic, person-centered care. We synthesise the evidence on physical health disparities in SMI and provide practical, evidence-based recommendations for psychiatric settings. Together, these strategies offer a feasible, person-centered framework to improve health outcomes and reduce premature mortality in individuals with SMI.

BACKGROUND:This study aims to explore for the first time the knowledge, understanding and management of sleep problems in children with ADHD among clinicians who specialise in sleep and ADHD. The aim was to inform the development of digital sleep awareness training for clinicians. METHOD/METHODS:Fifteen clinicians who work with children with ADHD and sleep difficulties in the United Kingdom participated in semistructured qualitative interviews. Data were analysed using a reflexive thematic analysis approach to generate and guide the content of digital sleep awareness training. RESULTS:Four core themes were developed: 'It's a Problem' highlighted the extent to which children with ADHD were reported to struggle with sleep difficulties and the impact this has on the child and family. Clinicians also discussed the difficulty they had in finding evidence-based information they could share with caregivers. With little to no formal training, most of the advice they gave came from 'learning on the job'. When discussing ADHD specific sleep difficulties and disorders, clinicians reflected on their own 'insight into limitations of knowledge'. 'Learning for practice' highlighted the divergence in the methods of learning preferred by clinicians, despite convergence of learning content needed. CONCLUSIONS:Sleep problems in children with ADHD are common, and clinicians often struggle to support these due to lack of formal training. There is a need for accessible, authoritative training for UK practitioners who work with children with ADHD.

BACKGROUND/UNASSIGNED:Umbrella reviews, or overviews of reviews, synthesize information using systematic reviews (SRs) as their unit of analysis. Although a formal guideline exists for reporting umbrella reviews of healthcare interventions (i.e. Preferred Reporting Items for Overviews of Reviews [PRIOR]), no formal guideline exists for conducting and/or reporting umbrella reviews of observational studies that examine epidemiological associations. OBJECTIVE/UNASSIGNED:To review the existing guidance on conducting and/or reporting umbrella reviews of observational studies on epidemiological associations, as part of the process of developing a formal reporting guideline. METHODS/UNASSIGNED:We reviewed the scoping review conducted in the context of PRIOR development and identified documents through forward citation search in PubMed, Scopus, and manual search in Google Scholar, Google Search up to December 22, 2024. Documents, regardless of format, were included if they provided guidance for conducting and/or reporting umbrella reviews of observational studies (including meta-research studies of their features). Title/abstract screening and data extraction were performed independently and in duplicate and summarized narratively by stages of the umbrella review process. RESULTS/UNASSIGNED:The search retrieved 4491 unique records, with 96 full texts assessed and eight documents included. These documents, published between 2014 and 2023, offered guidance across seven topic areas, but overall guidance on conducting and/or reporting is limited. These areas include the answerable questions, prerequisite considerations, the scope of umbrella reviews, searching for SRs, primary data collection, analysis, presentation, and assessing the certainty/quality of the body of evidence. CONCLUSION/UNASSIGNED:There is a need for dedicated, practical, and evidence-based formal reporting guidelines for umbrella reviews of observational studies on epidemiological associations. This review lays the groundwork for developing the PRIOR-extension for such studies: the Preferred Reporting Items for Umbrella Reviews of Cross-sectional, Case-control, and Cohort Studies.

When thoroughly assessed, the prevalence of attention-deficit hyperactivity disorder (ADHD) in children/adolescents is estimated at 5%. There is no evidence that ADHD is over-diagnosed in the UK. Indeed, available data point to under-diagnosis, even though rigorous updated post-COVID-19 pandemic data are not available. Some cases may be misdiagnosed due to low-quality assessment, poor adherence to national guidance or inappropriate differential diagnosis. Beyond the controversy around over- or under-diagnosis and over-medicalisation of ordinary behaviours or emotions, the main issue is that UK clinical services cannot adequately support individuals with ADHD who need help. There is a risk that the narrative claiming 'ADHD is over-diagnosed' could be used to deny people with properly-diagnosed ADHD the care they deserve.

OBJECTIVES/OBJECTIVE:Adolescents transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) may face challenges in accurately identifying and reporting their mental health symptoms, often leading to discrepancies between clinician and patient evaluations. Using data from the MILESTONE project, this study aims to assess clinician-adolescent concordance over 24 months and identify domains of psychopathology with the highest disparities. METHODS:Participants were assessed at baseline, 9, 15, and 24 months using the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scale and were categorized in four diagnostic groups. Hierarchical cluster analysis identified symptom-based subgroups of patients based on clinician and patient-rated HoNOSCA scores. Concordance was evaluated through multilevel linear regression models, while Bland-Altman plots examined agreement between scores across time points. RESULTS:Two clusters of patients were identified: one characterized by lower severity and greater prevalence, the other by higher complexity and fewer individuals. Clinician-patient concordance increased over time, rising from 77% to 83% by the second time point and stabilizing. Concordance varied across diagnostic categories, with anxiety showing the highest agreement and ADHD the lowest. CONCLUSIONS:Improved communication, psychoeducation, and tailored interventions may facilitate greater patient-clinician alignment, thereby supporting more favorable outcomes during this critical developmental period. TRIAL REGISTRATION/BACKGROUND:ISRCTN83240263; NCT03013595.

BACKGROUND AND OBJECTIVE/OBJECTIVE:Individuals with attention-deficit/hyperactivity disorder, their families and clinicians may report worsening symptoms despite compliant use of medication, suggesting potential tolerance, but evidence remains conflicting. Some studies have also suggested tachyphylaxis, or acute tolerance, though research is limited. We conducted the first systematic review of empirical studies focussing on tolerance/tachyphylaxis to attention-deficit/hyperactivity disorder medication to clarify their potential clinical relevance. METHODS:As registered on PROSPERO (CRD42024594759), we searched PubMed, OVID (including PsychInfo and MEDLINE) and Web of Knowledge up to 1 September, 2024, and assessed the risk of bias using National Institutes of Health quality assessment tools. RESULTS:The identified 17 studies were either interventional or observational, and varied greatly in design and duration. Four investigated tachyphylaxis, nine tolerance to the subjective and behavioural effects, and four tolerance to cardiovascular effects. We found preliminary evidence of tachyphylaxis to the affective or behavioural effects of stimulants, as well as tolerance to the subjective effects of d-amphetamine, such as drug liking and excitation, in neurotypical volunteers in the short term. Conversely, there was little or no evidence for tolerance to the therapeutic or cardiovascular effects of attention-deficit/hyperactivity disorder medication in clinical settings in the longer term. Quality was rated as low in most studies because of small sample sizes and methodological limitations. CONCLUSIONS:Overall, these results do not support the hypothesis that tolerance commonly develops to the therapeutic effects of attention-deficit/hyperactivity disorder medication, although robustly designed longitudinal studies are needed to provide more conclusive evidence. Clinicians may consider other potential explanations for reduced therapeutic effects over time, including natural fluctuations of symptoms, limited compliance, life events and co-occurrent mental health conditions.

This is the first bottom-up review of the lived experience of persons who attempt suicide. The study has been co-designed, co-conducted and co-written by experts by experience and academics, focusing on first-person narratives within and outside the medical field. The lived world of individuals who attempt suicide is characterized by experiences related to the attempt itself ("contemplating suicide as a deliberate death", "contemplating suicide as an escape route", "looking for online answers about suicide", "planning suicide", "finding rest between the suicidal decision and the final act", "changing one's mind during the suicide attempt", "acting on suicidal impulses"); experiences related to the self and time ("feeling unworthy", "feeling detached from oneself or the world and lacking a sense of agency", "splitting the self between the decision to live or die", "perceiving an abortive and doomed future"); and experience of emotions and the body ("feeling overwhelmed by hopelessness and despair", "feeling empty and drained of energy", "feeling alone"). The lived experience of individuals who attempt suicide is also described in terms of the social and cultural context, including the experience of others ("feeling that no one cares", "feeling like a burden to others", "facing others' difficulty in understanding"); cultural, gender and age differences ("experiencing geographical, cultural and religious taboos about suicide", "feeling inadequate in relation to gender stereotypes", "feeling abandoned in old age"); and the perception of stigma ("facing social stigma", "experiencing a stigmatized self", "silencing suicidal behaviors"). The lived experience of persons after an attempted suicide is characterized as a complex process of self-acceptance and rediscovery ("living with suicidal thoughts", "navigating the challenges of recovery", "gaining new perspectives during recovery", "restoring interpersonal relationships to recover"). Finally, the lived experience of individuals who attempt suicide is described with respect to their access to general health care ("seeking help before the suicide attempt", "feeling abandoned after a suicide attempt") and mental health care ("experiencing shame as a barrier to care", "fearing mental disorder label", "feeling accepted and listened to", "facing economic difficulties in accessing support", "coping with distress during hospitalization"). The experiences described in this paper hold educational and social value, informing medical and psychological practices and research, public health approaches, and promotion of social change. This research overcomes embarrassment, fear and stigma, and helps us to understand the fragile nature of our emotions and feelings, our immersion in the social world, and our sense of meaning in life.

External trigeminal nerve stimulation (TNS) received US Food and Drug Administration clearance in 2019 as the first device-based, non-pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD), based on a small pilot sham-controlled randomized controlled trial (RCT) that reported symptom improvement in 62 children with ADHD. Here we conducted a confirmatory multicenter, double-blind, randomized, sham-controlled, parallel-group, phase 2b RCT to investigate short-term and long-term efficacy (6 months) of real versus sham TNS in 150 children and adolescents with ADHD. Participants were randomized to receive real TNS (n = 75, mean age (s.d.) = 12.6 (2.8) years) or sham TNS (n = 75, mean age (s.d.) = 12.6 (2.8) years) nightly for approximately 9 hours for 4 weeks. Bilateral stimulation targeted V1 trigeminal branches using battery-powered electrodes applied to the forehead. Sham TNS delivered 30 seconds of stimulation per hour at lower frequency and pulse width. Intention-to-treat analysis showed no significant differential treatment effects on ADHD symptoms (primary outcome) (estimated adjusted mean difference = 0.83; 95% confidence interval: -2.47 to 4.13; P = 0.622; Cohen's d = 0.09). No serious adverse events were reported, and side effects did not differ between groups. In conclusion, TNS is a safe intervention but does not demonstrate clinical efficacy for pediatric ADHD. Trial registration: ISRCTN82129325 .

BACKGROUND:People with mental disorders have an increased risk of diabetes, yet conflicting evidence exists regarding the quality of diabetes care they receive. To address this evidence gap, we conducted a systematic review and meta-analysis to assess and compare diabetes quality of care in people with diabetes with mental disorders versus people with diabetes without mental disorders. METHODS:test, blood pressure measured, foot surveillance, serum creatinine test, serum cholesterol test, BMI recorded, smoking status recorded, retinal monitoring). Secondary outcomes were study-specific diabetes quality of care individual indicators matched to the nine NICE diabetes monitoring indicators and specific diabetes interventions and anti-diabetes medications. We analysed primary and secondary outcomes according to any mental disorder and to specific diagnostic subgroups. Study quality was evaluated using the Newcastle-Ottawa Scale (NOS). FINDINGS/RESULTS:measurement (24 studies, 0·81 [0·68-0·97], p=0·024), retinal screening (21 studies, 0·77 [0·63-0·95], p=0·013), lipid and cholesterol measurement (20 studies, 0·83 [0·69-0·99], p=0·043), foot examination (11 studies, 0·85 [0·76-0·95], p=0·0044), and renal investigation (16 studies, 0·78 [0·63-0·96], p=0·022). A significant positive association was found between any mental disorder and recorded smoking status (two studies, 1·09 [1·02-1·17]; p=0·0076). Any mental disorder was significantly associated with higher odds of receiving insulin (ten studies, 1·52 [95% CI 1·16-1·99]; p=0·0022), but negatively associated with treatment with a GLP-1 receptor agonist (two studies, 0·26 [0·13-0·49]; p<0·0001). There was no evidence of publication bias. INTERPRETATION/CONCLUSIONS:Mental disorders are negatively associated with receiving adequate diabetes monitoring and GLP-1 agonist therapy. Addressing these disparities has the potential to address the increased mortality associated with mental disorders. FUNDING/BACKGROUND:None.

In this Personal View, we address key questions to support evidence-based prevention and management of psychotic symptoms that might occur during ADHD pharmacotherapy. We begin by examining evidence showing a significantly increased occurrence of psychotic disorders in individuals with ADHD, independent of ADHD medications (pooled relative risk, odds ratio, or hazard ratio=4·74, 95% CI 4·11-5·46). We then examine whether ADHD medications play a causal role, noting that current evidence does not support such a causal link, at least for methylphenidate. We explore how vulnerability to psychosis varies across individuals with ADHD. Regarding the different steps involved in prescribing ADHD medications, we discuss the importance of balancing potential risks-such as emergence of psychotic symptoms-against the demonstrated benefits of pharmacological treatment for ADHD. Next, we present strategies for screening individuals for vulnerability to psychosis before initiating ADHD medication. We then offer guidance on the clinical management of psychotic symptoms that might arise during ADHD pharmacotherapy, including considerations of dosage and medication type. Finally, we identify key research priorities in this area. Overall, this paper provides an empirical framework, grounded in evidence and clinical practice, to guide the next steps in the field.